Acute Care of Patient in Clinical Cases Essay
Acute Care of Patient in Clinical Cases Essay
Download and analyze the case study for this week. Create a SOAP note for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care. Acute Care of Patient in Clinical Cases Essay
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Visit the online library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the CDC, WHO, AHRQ, Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.
Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information. Acute Care of Patient in Clinical Cases Essay
Download the access codes.
Download the SOAP template to help you design a holistic patient care plan. Utilize the SOAP guidelines to assist you in creating your SOAP note and building your plan of care. You are expected to develop a comprehensive SOAP note based on the given assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions and incorporate the knowledge that you have gained into your patient’s care plan. If the information is not in the provided scenario please consider it normal for SOAP note purposes, if it is abnormal please utilize what you know about the disease process and write what you would expect in the subjective and objective areas of your note. Acute Care of Patient in Clinical Cases Essay
SOAP NOTE
Name: | Date: | Time: | ||
Age: | Sex: | |||
SUBJECTIVE | ||||
CC:
Reason given by the patient for seeking medical care “in quotes”
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HPI: Use OLDCART acronym
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
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Medications: (list with reason for med ) write medicine the same way you write a Rx
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PMH (list approximate year of Dx of the disease or when surgical procedure performed)
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
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Family History (list immediate family, age, disease, and whether is dead or alive)
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
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Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status
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ROS (Start each sentence with words such as “Denies, admits, complains, reports”, do not use the words “No, positive for, negative for”. Do NOT list physical exam findings here. If the body system not assess write “Non-Contributory” | ||||
General
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Cardiovascular
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Skin
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Respiratory
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Eyes
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Gastrointestinal
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Ears
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Genitourinary/Gynecological
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Nose/Mouth/Throat
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Musculoskeletal | |||
Breast | Neurological | |||
Heme/Lymph/Endo | Psychiatric | |||
OBJECTIVE- this is where you document physical exam findings, do NOT use the word NORMAL to document a finding, and instead explain what normal is. For example, the gait is not normal, the gait is steady. If the body part not assessed then type “Deferred”. Acute Care of Patient in Clinical Cases Essay | ||||
Weight BMI | Temp | BP | ||
Height | Pulse | Resp | ||
General Appearance | ||||
Skin | ||||
HEENT | ||||
Cardiovascular | ||||
Respiratory | ||||
Gastrointestinal | ||||
Breast | ||||
Genitourinary
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Musculoskeletal | ||||
Neurological | ||||
Psychiatric | ||||
Lab Tests (lists any tests ordered and status of the test, if a rapid test was done at the office, list the results) Acute Care of Patient in Clinical Cases Essay
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Special Tests (List any imaging study or special test ordered and status of the test, if the result is available, write the result)
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Diagnosis | ||||
Differential Diagnoses with ICD 10 codes (these are Dx you considered, but then ruled out)
Diagnosis with ICD 10 Code o CPT Code/Office visit code:
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Plan/Therapeutics | ||||
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Evaluation of patient encounter
Document your level of interaction with the patient. Weaknesses: Strengths: Reflection: |
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References:
Acute Care Of Pneumonia Patient Case Nursing Essay
M.F. is a 37-year-old male presenting to the Emergency Department with dypsnea at rest that has been present for two to three weeks. His condition has worsened over the past two days. He presented with rapid respirations, complaints of periodic confusion, nasal flaring, and irritability. He had an occasional nonproductive cough and was afebrile. The chest x-ray showed bilateral effusion and possible pericardial effusion. Acute Care of Patient in Clinical Cases Essay
This patient is non-compliant with hemodialysis. On admission to the Emergency Room he had an elevated blood urea nitrogen and creatinine.
Primary Diagnosis and Priority Secondary Diagnosis
M.F. was admitted to the hospital with a primary diagnosis of pneumonia and a secondary diagnosis of chronic renal failure.
Patient History
M.F. has a history of failed renal transplants times two. He also has severe pulmonary hypertension and chronic heart failure. M.F. is non-compliant with his dialysis; he is supposed to have dialysis three times a week. He currently only goes twice per week. The patient is a smoker of one half pack per day and at this time has no plans to quit. He lives with his fiancée, who is present at the patient’s bedside. Acute Care of Patient in Clinical Cases Essay.
PATHOPHYSIOLOGY OF THE PRIMARY AND PRIORITY SECONDARY DIAGNOSIS
Pneumonia is an excess of fluid in the lungs resulting from the inflammatory process. Inhaling infectious organisms or agents that irritate the lungs can trigger inflammation. The inflammation occurs in the alveoli, bronchioles and interstitial spaces of the lungs. Organisms multiply within the alveolar spaces causing an immune response. White blood cells migrate to the area causing local capillary leak, edema, and exudates. These fluids collect in and around the alveoli, thickening the walls and thus reducing gas exchange. This leads to hypoxia. If the organisms move into the blood stream sepsis results. Acute Care of Patient in Clinical Cases Essay.
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The fibrin and edema cause a stiffening of the lungs. This stiffening reduces lung compliance, decreasing the lungs vital capacity. The inflammation of the alveoli causes collapse, further reducing the oxygenation of the blood.
People develop pneumonia when their immune systems are unable to combat the virulence of the invading organisms. Bacteria, viruses or fungi can cause pneumonia. Inhalations of toxic gases or aspiration are among other causes of pneumonia (Ignatavicius & Workman, 2006).
Patients with pneumonia have flushed cheeks, bright eyes, and an anxious expression. They may have pleuritic pain or discomfort, myalgia, headache, chills, fever, cough, tachypnea, tachycardia, and sputum production. Crackles are heard when there is fluid in the interstitial and alveolar spaces. Wheezing may be heard when there is inflammation and exudates in the airways. These patients may be hypotensive as a result of vasodilatation and dehydration. Acute Care of Patient in Clinical Cases Essay
Chronic renal failure is an irreversible kidney injury. This disease is progressive and ends with the kidney function being too poor to sustain life. The first sign is diminished reserve. In this stage there is no build up of metabolic wastes in the blood. The unaffected nephrons can compensate for the injured nephrons. As renal damage increases systemic blood pressure increases, causing increased glomerular pressure, which will damage more nephrons. As more nephrons are damaged the patient progresses to renal insufficiency. This stage has a build up of metabolic waste in the blood stream. Levels of blood urea nitrogen and creatinine increase, the kidneys are no longer able to maintain hemostasis. Acute Care of Patient in Clinical Cases Essay
Three main causes of renal failure include diabetes mellitus, hypertension, and glomerulonephritis. Polycystic kidney disease, a hereditary renal disorder, in adults can lead to chronic renal failure.
Chronic renal failure can cause lethargy, seizures or coma. The patient is at risk for fluid overload, hypertension or heart failure. They may also have breath that smells of urine, shortness of breath or tachypnea. In later stages the patient may experience anemia or abnormal bleeding. As kidneys fail the patient may have oliguria. The skin may become itchy or develop a layer of crystals called uremic frost (Ignatavicius & Workman, 2006).
M.F. suffers from shortness of breath, due to increased fluid build up. The fluid builds in his lungs from his chronic renal failure, giving bacteria a place to multiply and causing the immune inflammatory response. Acute Care of Patient in Clinical Cases Essay
ACTUAL OR POTENTIAL IMPACT OF RELEVENT MEDICAL HISTORY ON THE PRIMARY DIAGNOSIS AND PRIORITY SECONDARY DIAGNOSIS
M.F. has a history of chronic renal failure. He also has a history of non-compliance with his dialysis. When M.F. does not get his dialysis he is at risk for fluid overload. This fluid builds up aggravating his hypertension and his chronic heart failure causing an increase in his pulmonary hypertension. By increasing the fluid in his lungs he decreases his gas exchange causing hypoxia. When the body senses hypoxia it starts to shut down the kidneys, causing a further fluid to build up and the decrease in the other functions of the kidney. One of which is production of erythropoietin. Since the kidneys are not producing this hormone, his body is not producing red cells, causing anemia. M.F. now further decreases his oxygenation levels, which could lead to a decrease in his level of consciousness, causing lethargy and confusion. M.F. had a low hemoglobin level that required treatment in the hospital (see medical management section). Acute Care of Patient in Clinical Cases Essay
MEDICAL MANAGEMENT: PNEUMONIA
Medical interventions for pneumonia include obtaining a sputum specimen for culture, a chest x-ray to look for areas of increased density, a complete blood count to identify white blood cells and red blood cells and hemoglobin for anemia, arterial blood gases, pulse oximetry for oxygenation. They could also include a blood urea nitrogen level to monitor for dehydration. Blood culture specimen to rule out sepsis. Monitor for signs and symptoms of infection. Acute Care of Patient in Clinical Cases Essay
M.F. had a slightly elevated white blood cell count (n=5.0-10.0) that ranged from 10.3 to 11.3 on discharge. His hemoglobin (n=14-18) was low upon admission at 7.9; he was given two units of packed red blood cells. His hemoglobin was still low upon discharge, at 10.9, but the patient was not lethargic, confused or short of breath.
X-ray on discharge showed a decrease in the size of infiltrates. M.F. remained afebrile throughout his admission. Upon discharge he was able to ambulate 50 yards, without any signs of distress. He had two negative blood cultures this admission. Acute Care of Patient in Clinical Cases Essay
To decrease the amount of fluid being retained M.F. was encouraged to follow a renal healthy diet. This would include foods low in protein, sodium and phosphorous (Medical College, n.d.). As kidney function declines these products build up in the blood stream. In order to lower the strain on his kidneys, M.F. was given instructions on foods that meet these criteria. M.F. was also encouraged to attend his dialysis three times per week, as directed by his physician. Hemodialysis is the most common type of dialysis. It uses a filter to remove waste products from the blood stream. It then returns the cleaned blood back to you (Castner, 2008).
NURSING INTERVENTIONS
Textbook recommendations for nursing interventions include cough and deep breathing, use of incentive spirometer, to improve lung compliance. It recommends monitoring vital signs and breath sounds, to assess for improvement of infection. Also recommended is adequate hydration to thin secretions. Acute Care of Patient in Clinical Cases Essay
M.F. was encouraged to cough and deep breath every hour. He was very lethargic on day one and did not try more than twice. He did increase his attempts on day two. He was given instruction on the incentive spirometer, and was encouraged to use this every hour. He made no attempts on day one. On day two he was able to raise the level to 750mm for three seconds. He increased his efforts and was able to keep the level up for four seconds and repeat this five times each hour upon discharge. The patient’s lung sounds cleared from crackles to clear by discharge. The patient’s respiratory rate returned to between 18-20 breaths per minute upon discharge. M.F. was kept to an 1800 ml per day fluid restriction, due to his increased fluid volume. He remained afebrile throughout his stay. He had a non-productive cough upon admission; this did not clear during his hospital stay. Acute Care of Patient in Clinical Cases Essay
PHARMACOLOGICAL MANAGEMENT
Treatment options include antibiotics to stop the spread of infection. Bronchodilators may also be used to improve gas exchange. The use of oxygen management is encouraged to increase oxygenation of the blood.
M.F. was on two liters of oxygen via nasal cannula and was able to maintain his pulse oximetry at a level between 92-95%. Upon discharge his pulse oximetry showed 95% on room air. He was started on Avelox (antiinfective) intravenously, and then changed to oral upon discharge. He remained afebrile throughout hospital stay. His white blood count rose slightly, but no other signs of bacterial infection was noted. Acute Care of Patient in Clinical Cases Essay
PROVIDER AND MANAGER ROLE: NURSING CARE PLAN
“P” Impaired gas exchange
“R” Ventilation-perfusion imbalance
“C” decreased level of consciousness, dypsnea at rest, decreased oxygen saturation <90%
Goal statement
The patient will show improving lung fields and remain free of respiratory distress, as evidenced by clearing chest x-ray and improved oxygen saturation levels by discharge.
Nursing interventions
The nurse will monitor patient’s respiratory rate, depth and effort including use of accessory muscles, nasal flaring and abnormal breathing patterns. The nurse will encourage the patient to cough and deep breath. The nurse will teach and encourage the use of the incentive spirometer hourly. Acute Care of Patient in Clinical Cases Essay
Evaluation of progress toward patient goal
M.F. had a hard time complying with the nursing interventions.
When using the incentive spirometer his lung sounds went from crackles to clear. His respirations went from 28 breaths per minute to 18. He maintained a pulse oximetry of between 92-95% on 2 liters of oxygen. He was able to ambulate in the hallway without respiratory distress. The chest x-ray taken on the day of discharge showed a decrease in the infiltrates in the patient’s lungs. This patient met his goals upon discharge. Acute Care of Patient in Clinical Cases Essay
PROVIDER AND MANAGER ROLE
Role of the Multi-Disciplinary Team
M. F.’s care depended on the ward clerks to order the appropriate tests at the appropriate times. It also included the ancillary services to do the tests as ordered. A nutrition consult was ordered to teach proper diet for a patient that has chronic renal failure. A mental health consult was ordered to evaluate the patient for depression. Also a social worker talked to the patient about his need for transportation to dialysis upon discharge. The discharge planner was also helpful in making dialysis appointments for this patient.
Provider of Care Role
As provider of care I monitored the patient’s vital signs, paying particular notice of his temperature to monitor for infection. I also evaluated M.F.’s breath sounds, noting improvement daily. I gave the patient his medications on time. I also encouraged the patient to cough and deep breath and use his incentive spirometer. I assisted M.F. in ambulation when needed. Acute Care of Patient in Clinical Cases Essay.
Manager of Care Role
As manager of care for this patient I needed to instruct him on the use of his incentive spirometer and the importance of using this equipment to increase his breathing ability. I also monitored his laboratory and radiology results to be sure these were done as ordered. I made sure all the doctors orders were noted in a timely manner and carried out as instructed. I gave this patient his discharge instructions and made sure he was knowledgeable about his diet. I answered any question M.F. had on the information given to him during his admission to the hospital. Acute Care of Patient in Clinical Cases Essay
Growth in the Manager of Care Role
I was able to see the importance of recognizing the affect of all co-morbidities of the patient. For each disease process there is an effect on other systems, and each of these effects must be taken into account when treating the patient.
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When teaching this patient I also was learning the things needed to help in achieving a healthier lifestyle for this patient. This helped me develop a knowledge base that I can build upon. Since this patient was not receptive to instruction, I had to find ways to get him to comply with his orders. I learned to depend on others on my team to help get the job done. Acute Care of Patient in Clinical Cases Essay